Special Exposure Cohort Petition U.S. Department of Heaith and Human Services
under the Energy Employees Occupational Centers for Disease Controi and Prevention
tlness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Page 5 of 7

Basis for Proposing that Records and Information are Inadequate for Individual Dose —
Complete Section F

Special Exposure Cohort Petition — Form B

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

Fa ®& We have attached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area
monitoring.

{Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that potential radiation exposures were not monitored.

Mh KECO WERE mn <ywovecs =
LLbLED Lb dade bay beater Fiver iz, JT A 00 EDGE
O8 Ca, 2 ww BLL iD.

F.2 x U We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the employees worked.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as compietely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been tost, altered illegally, or destroyed.

Me Lhaliretiiwe tbs Dow é CAZZACHER

Part F is continued on the following page.

Name or Social Security Number of First Petitioner:


|Special Exposure Cohort Petition

under the Energy Employees Occupational
Hiness Compensation Act

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

OMB Number. 0820-0639 Expires: 07/31/2010

Page 4 of 7

E.2 Locations at the Facility relevant to this petition:
Au Agess ~ See Arrscved

E.3 List job titles and/or job duties of employees included in the class. In addition, you can list by
i duals other than petitioners identified on this form who you believe should be
E4 Em-* ‘7 ‘es relevant to this petitior-
Stal 1474 End _ [212 See AT7yweD
Stan End
Start End
ES

Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: O Yes Mi No

If yes, provide the date(s) of the incident{s) and a complete description (attach additional pages
as necessary):

Go to Part F.

Name or Social Security Number of First Petitioner: ___


Special Exposure Cohort Petition
under the Energy Employees Occupational
Niness Compensation Act

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National institute for Occupational Safety and Health
OMB Number. 0920-0639 Expires: 07/31/2010
Page 6 of 7
F.3. Q (We have attached a report from a health physicist or other individual with expertise in
Tradiation dose reconstruction documenting the limitations of existing DOE or AWE records on
radiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions for

members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.

Special Exposure Cohort Petition — Form B

(Attach report to the back of the petition form.)

F.4 Q IWe have attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a lack
of monitoring or the destruction or loss of records) for estimating the radiation doses of
employees covered by the petition.

(Attach report to the back of the petition form.)

Go to Part G.
Complete Section G.
All Petitioner: «imum of three persons may sign the petition.
_ TAM LP. POLS
Signatc Date
Signature Date
Signature Date
Notice:

Any person who knowingly makes any false statement, misrepresentation, concealment of
fact or any other act of fraud to obtain compensation as provided under EEQICPA or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both. | affirm that the information
provided on this form is accurate and true.

Send this form to: SEC Petition

Office of Compensation Analysis and Support

NIOSH

4676 Columbia Parkway, MS-C-47

Cincinnati, OH 45226

If there are additional petitioners, they must complete the Appendix Forms for additional petitioners.
| The Appendix forms are located at the end of this document.

Name or Social Security Number of First Petitioner: _


Special Exposure Cohort Petition U.S. Department of Health and.Human Services|
under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National institute for Occupational Safety and Health
OMB Number. 0920-0639 Expires: 07/31/2010
Page 1 of 7
Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitled.

Special Exposure Cohort Petition — Form B

General Instructions on Completing this Form (complete instructions are available in a separate packet):
Except for signatures, please PRINT ail information clearly and neatly on the form.

Please read each of Parts A — G in this form and complete the parts appropriate to you. If there is more
than one petitioner, then each petitioner should complete those sections of parts A — C of the form that apply

to them. Additional copies of the first two pages of this form are provided at the end of the form for this pur-
pose. A maximum of three petitioners is allowed.

lf you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

If you have questions about the use of this form, please call the following NIOSH toll-free phone number and

request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition:
1-877-222-8570.

OQ A Labor Organization, StartatD on Page3

If you Q An Energy Employee (current or former), StartatC on Page 2
are: i] A Survivor (of a former Energy Employee), StartatB on Page 2
QO A Representative (of a current or former Energy Employee), StartatA on Page1

A Representative Information — Complete Section A if you are authorized by an Employee or

Survivor(s) to petition on behalf of a class.

Ad Are you a contact person for an organization? 0) Yes (Go to A.2) Q No (Go to A3)
A.2 Organization Information:

Name of Organization

Position of Contact Person

A3 Name of Petition Representative:

MrJ/Mrs./Ms. First Name Middle Initial Last Name
A4 Address:

Street Apt # P.O. Box
City State . Zip Code
A5 Telephone Number: » =

A6 Email Address:

A7  Q Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization

If you are representing a Survivor, go to Part B; if you are representing an Employee, go to Part C.

Name or Social Security Number of First Petitioner:


Special Exposure Cohort Petition
under the Energy Employees Occupational
liness Compensation Act

U.S. Department of Health and Human Services
Centers for Disease Contro! and Prevention

Nationa! Institute for Occupational Safety and Health

OMB Number. 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B Page 7 of 7

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 300 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.

Persons are not required to respond to the information collected on this form untess it displays a currently
valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the
following:

The Energy Employees Occupational iliness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEO!CPA authorizes HHS to implement its responsibilities with the
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional

classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EECICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.

Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed
below.

NIOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal
agencies, other goverment or private entities and to private sector employers to permit these entities to
retrieve records required by NIOSH; (b) identified witnesses as designated by NICSH so that these
individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a
Congressional! staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these

forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to
provide required information may not be considered by HHS.

Name or Social Security Number of First Petitioner: __


Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control] and Prevention
liness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Page 2 of7
ea Survivor or representing a Survivor.

Special Exposure Cohort Petition — Form B
Survivor Informati

B.1 Name of Se

— Complete Section B if you

First Name Middle Initial Last Name
B.2 Social Security Number of Survivor: _
BQ Radannn nf Crete
Chen at antH P.O. Box
City State Zip Code

B.4 Telephone Number of Survivor:
B.S Email Address of Survivor:

B.6& Relationship to Employee: Spouse Q Son/Daughter Q Parent
Q Grandparent Q Grandchild
Go to Part C.

CA Name of Er "> ”

First Name Middle Initial Last Name _
C.2 Former Name of Employee (e.g., maiden name/legal name change/other):

Mr/Mrs./Ms. First Name Misia Initial 1 act Name

C.3 Social Security Number of Employee:
C.4 Address of Employee (if living):

Street Apt # P.O. Box
City State Zip Code
C.5 Telephone Number of Employee: 1

C.6 Email Address of Employee:
C.7_ Employment Information Related to Petition:

C7a Employee Number (if known): Cito uta
C.7b Dates of Employment: Start 1949 End 1278
C.7e Employer Name: Dazuveson Cremicat Cmggay

C.7d Work Site Location: PASA DE ALA TEXAS Ln. AkiDs of faAwr
SEE ATTACHED
C.7e SupenisorsName: _. €E A77ACHED

Goto” ~~

Name or Social Security Number of First Petitioner: __


Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
liness Compensation Act National Institute for Occupational Safety and Health

OMB Number. 0920-0639 Expires: 07/31/2010
posure Cohort Petition — Form B Page 3 of 7

Labor Organization Information — Complete Section D ONLY if you are a labor organization.
D.1 Labor Organization Information: “

Speciat

Name of Organization

Position of Contact Person
D.2 Name of Petition Representatjve: /

D.3 Address of Petition Repro

Street Apt # P.O. Box
City State ‘ Zip Code
D4 Telephone Number of Petition Representati ef )

D.5 Email Address of Petition Représentative:

D.6 Period during which labor o)
(please attach documentatio

nization represented employees covered by this petition
Start \ End

D.7__ Identity of other labor organizations that may represent or have represented this class of
| employees (if known):

Go to Part E.

Name or Social Security Number of First Petitioner: